Modified Distal Shoe

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JDC CASE REPORT

Modied Distal Shoe Appliance-Fabrication andClinical Performance

Kumar Raghav Gujjar, BDS, MDS K.R. Indushekar, BDS, MDS H.V. Amith, BDS, MDS Shefali Sharma, BDS, MDS

ABSTRACT

When the primary second molar is prematurely lost, mesial movement and migrationof the permanent first molar often occurs. This is one of the most difficult problemsof the developing dentition confronted by pediatric dentists. Use of a space maintainerthat will guide the permanent first molar into its normal position is indicated. Incases with bilateral premature loss of primary molars, the conventional design of distalshoe poses a variety of problems and, therefore, necessitates a customized design forthe eruption guidance of permanent first molars. The purpose of this case report is todiscuss an innovative design of a distal shoe appliance, which was used with goodclinical results. ( J Dent Child 2012;79(3):185-8)

Received April 1, 2011; Last Revision November 19, 2011; Revision Accepted

November 23, 2011.

K : , ,

Dr. Gujjar is senior lecturer, Department of Pediatric Dentistry, School

of Dentistry, Al-Arab Medical University, Benghazi, Libya; Dr. Indushekar

is graduate program director, professor, and chair, Department of

Pediatric Dentistry and Preventive Dentistry, Sudha Rustagi College

of Dental Sciences and Research, Faridabad, India; Dr. Amith is

reader, Department of Community Dentistry, People’s College of

Dental Sciences and Research Center, Bhopal, India; and Dr. Sharma

is senior lecturer, Department of Periodontics, Seema Dental College

and Hospital, Rishikesh, India.

Correspond with Dr.Gujjar at [email protected]

One of the most valuable tools that pediatric den-tists can use when a primary second molar islost prematurely is the distal shoe appliance

(DSA ), which helps guide the permanent first molar intoplace. Te distal shoe space maintainer was first intro-duced by Gerber1 and modified by Croll.2,3 Its indica-tions and contraindications were discussed in detail byHicks,4 who preferred fabrication of a cast gold appli-ance, although appliances with attachments solderedto stainless steel crowns or bands were clinically accept-able. Brill5 described chairside fabrication of a distal

shoe space maintainer to be delivered immediately afterthe extraction which showed a high success rate if thepatient was cooperative.Tere are several conditions that contraindicate the

use of the DSA. If several teeth are missing, abutments

to support a cemented appliance may be absent. Pooral hygiene or lack of patient and parental cooperatigreatly reduces the possibility of a successful clinicresult. Certain medical conditions, such as blood dyscrsias, immunosuppression, congenital heart defecrheumatic fever, diabetes, and generalized debilitatiomay be a contraindication to its use. Cases in whiDSA use is contraindicated, 2 possibilities for treament exist:1. Allow the tooth to erupt and regain space later.2. Use a removable or fixed appliance that does n

penetrate the tissue but places pressure on the ridmesial to the unerupted permanent molar.6 Carroll and Jones reported 3 cases in which a removab

or fixed pressure appliance was used to guide the permnent molar as it erupted.7 Te purpose of this case report is to describe the clin

cal management of extensively carious primary mandbular molars with a modified DSA.

CASE REPORT A 5-year-old boy reported to the Department of Pediat

Dentistry, S.D.M College of Dental Sciences, DharwaIndia, with a chief complaint of pain and recurrent sweing on the posterior area of the mandible bilaterally. H


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medical history was non-contributory. A clinical exami-nation revealed a grossly decayed primary mandibularleft second molar and a primary mandibular left firstmolar restored with an occlusal amalgam followinga pulpotomy. Both primary mandibular right molarspresented extensive caries with only root stumps remain-ing (Figure 1). The patient’s oral hygiene was fair atfirst and the the appliance was only considered afteran improvement was seen.

A periapical radiograph of the left mandibular post-erior area showed a large periapical abscess in the pri-mary second molar (Figure 2). A periapical radiographof the right mandibular posterior area revealed rootstumps of both primary molars (Figure 3).

A modified DSA was planned, consisting of a stain-less steel crown retainer (3M ESPE, St. Paul, Minn.,USA) on the primary mandibular left first molar and aband adapted on the primary mandibular right canine. A wire component consisted of a lingual-arch, which wasextended bilaterally as a distal shoe using a 0.8-mm

gauge orthodontic stainless steel wire.T

e lingual arch wire was placed as lingually as possible so as to notinterfere with with the eruption of the permanent man-dibular incisors. The length of the horizontal arm was measured on bo th side s on the preo perat iveradiographs. The vertical depth of the intragingivalextension was calculated radiographically, approxi-mately about 1.5 mm below the mesial marginal ridge,

just sufficient to touch the mesial surface of the permnent mandibular first molars. A vertical cut was maon the working model, and the wire components weadapted on both sides, then soldered to the stainlesteel crown and the band on the primary mandibulright canine.

After obtaining informed consent from his parenextraction of the root stumps of the primary madibular right first and second molars and the grossly d

cayed primary mandibular left second molar was peformed. Before cementing the appliance, a radiograp was obtained to determine the proper relationship the tissue extension with the unerupted first permanemolars (Figures 4 and 5). Final adjustments in lengand contour were made prior to cementation. Aftcementing the appliance with type I glass ionomluting cement (GC Fuji, Tokyo, Japan), appropriate istructions were given to the patient regarding applianand oral hygiene maintenance. Figure 6 shows the itraoral view of the appliance 24 hours after insertion.T

e patient was recalled every month for a checkuto evaluate the integrity of the appliance and supporing teeth and the eruption status of the permanemandibular first molars and permanent mandibulincisors. Te patient’s parents were asked to assist hi with toothbrushing because his oral hygiene had dteriorated. Two months later, the permanent mandbular first molars had erupted (Figure 7). Clinicall

Figure 1. Preoperative intraoral photograph.

Figure 2. Preoperative radiograph of the primary mandibular left

molar region.

Figure 3. Preoperative radiograph of the primary mandibular right

molar region.

Figure 4. Radiograph of the primary mandibular left molar region

showing the relationship of the distal shoe extension with the un-

erupted permanent rst molar prior to cementation


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Figure 5. Radiograph of the primary mandibular right molar region

showing the relationship of the distal shoe extension with the unerupted

permanent rst molar prior to cementation.

Figure 6. Intraoral photograph of the distal shoe appliance in place

24 hours after cementation.

Figure 7. Photograph showing the appliance during the 2-month follo

up with the permanent mandibular rst molars erupted.

they showed white opacities and rounded cusps on theocclusal surfaces, probably due to enamel hypoplasia.Te staining present on the occlusal surface may havebeen due to difficulty in maintaining the oral hygienein the posterior region. Radiographically, the reasonfor the apparent changes in the periodontal spaceobserved post-operatively on the mandibular primaryfirst molar could be due to a change in the angulationof the radiograph or an improvement of the periapical

condition (Figure 8).Te patient tolerated the appliance well, despite his

difficulties with oral hygiene. After the permanent man-dibular first molars erupt completely, the DSA will bereplaced with a bilateral band and loop space main-tainer. A short span on the left side and a long span onthe right side will be created, with the erupted perma-nent mandibular first molars used as an abutment untilthe permanent mandibular incisors erupt after whicha lingual arch space maintainer could be placed.

DISCUSSION Management of cases with prematurely lost bilateralprimary molars is a clinical challenge for pediatric den-

tists. The conventional design of the DSA cannot used in clinical situations with multiple tooth loss.Te disadvantages with removable space maintaine

such as requiring cooperation by the patient and tpossibility of being lost or broken, have led to a prefence for fixed space maintainers. Foster reported that wel l-designed fixed space maintainer could be mopreferable than a removable appliance.8

Figure 8. Radiograph of the primary mandibular left molar region

during the 2-month follow-up.

Figure 9. Radiograph of the primary mandibular right molar region

during the 2-month follow-up .


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In the present case, modification of the fixed DSA was considered to aid the guidance of the permanentmandibular first molars bilaterally. This modificationoffers the following advantages: simple design withminimal adjustment, increased stability and strength,ability to maintain the mesiodistal space bilaterally,favorable eruption guidance of the permanent mandi-bular first molars bilaterally, better appliance inte-grity, and better acceptance and tolerability by

the patient. Disadvantages of this appliance includedifficulty in its construction, high expense involved,and difficulty maintaining oral hygiene. It is a non-functional appliance, the use of which may be difficultin highly uncooperative patients.Te bilateral distal shoe design discussed in this case

may be considered as a short-term appliance for guid-ing permanent mandibular first molars. The lingualarch portion of the design may cause interference withthe eruption of permanent mandibular incisors. Hence,the duration of use of the appliance was subjected to

close monitoring of eruption of permanent mandi-bular incisors clinically and radiographically. Oncethe permanent mandibular incisors erupt, it would beprudent to replace the appliance with a lower lingualholding arch space maintainer. Alternatively, the appliancemay be modified by placing the lingual arch wire morelingually in such a way that it doesn’t interfere with theeruption of the permanent mandibular incisors as wellas tongue movement.

Te time frame for which the appliance was used wshort (approximately 2 months). Long-term clinicstudies are dictated to determine the efficacy of thappliance.Te present report showed that this customized DS

was stable and showed acceptability by the patient.

REFERENCES 1. Gerber WE. Facile space maintainer. J Am De

Assoc 1964;69:691-4. 2. Croll TP. An adjustable intra-alveolar wire for d

tal extension space maintenance: A case reportPedod 1980;4:347-53.

3. Croll TP, Sexton TC. Distal extension space maitenance: A new technique. Quintessence Int 19812:1075-80.

4. Hicks EP. Treatment planning for the distal shspace maintainer. Dent Clin North Am 1973;1135-50.

5. Brill WA. Te distal shoe space maintainer chaside fabrication and clinical performance. Pedia

Dent 2002;24:561-5. 6. McDonald RE. Dentistry for the Child and Ad

lescent. 8th ed. Philadelphia, Pa: C.V. Mosby C2004:636-8.

7. Carroll CE, Jones JE. Pressure-appliance therafollowing premature loss of primary molars. ASD J Dent Child 1982;49:347-51.

8. Foster TD. Dental Factors A ff ecting Occlusal Deelopment: A Textbook of Orthodontics. LondoUK: Blackwell; 1990:129-46.


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